Provider Demographics
NPI:1952351769
Name:MATRISCIANO, JAMES G (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:G
Last Name:MATRISCIANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21333 HAGGERTY RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-5510
Mailing Address - Country:US
Mailing Address - Phone:248-662-0250
Mailing Address - Fax:
Practice Address - Street 1:15704 MEDICAL ARTS DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1446
Practice Address - Country:US
Practice Address - Phone:985-542-0110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10153R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1976725Medicaid
LAP00113832OtherRR MEDICARE 001
LAP00296719OtherRR MEDICARE 099
LA1976725Medicaid
LAP00113832OtherRR MEDICARE 001
LA4F662CH88Medicare ID - Type UnspecifiedLA001